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Alpha Health

Alpha Individual Health

Why Madison Alpha Individual Health?

  •   Access to countrywide service provider network
  •   Smart card based
  •   Declared pre-existing chronic, non chronic and AIDS
  •   Lodger fees for children below 8 years of age
  •   Overseas emergency treatment for the first 45 days of travel
  •   Local emergency road and air evacuation
  •   Psychiatric illness
  •   First emergency cesarean section
  •   Congenital conditions
  •   Inpatient non accidental optical benefit including laser treatment
  •   Inpatient non accidental dental benefit
  •   Post hospitalization review expenses up to 21 days after discharge
  •   Free last expense

Main Benefits

In Patient Benefits

  • Admission in a NHIF accredited hospital
  • Accommodation for parent/ guardian accompanying a child below 8 years
  • Doctors; surgeons; and specialist’s fees
  • Laboratory investigations, X-rays, ultra sound, ECG, MRI scans
  • Prescribed drugs, dressings, surgical appliances, and nursing procedures
  • Theatre charges including Surgeons and anesthetists fees
  • Intensive care (ICU)/High Dependency unit(HDU)
  • Radiotherapy, chemotherapy, physiotherapy
  • Gynecological treatment
  • Day Care surgery
  • Prematurity covered within the congenital conditions limit (available if client has maternity cover)

Out Patient Benefits

  • Consultation with a general practitioner and specialist
  • Diagnostic examinations
  • Prescription medicines
  • Outpatient procedures e.g. dressing
  • Immunizations and vaccinations for children (KEPI recommended)
  • Minor trauma treatment
  • Gynecological treatment

Maternity Benefits

  •  Delivery expenses
  •  Maternity related complications
  •  Pre and post natal care
  •  Caesarean section

Dental Benefits

  •   Cost of fillings
  •   Root canal
  •   X-rays
  •   Polishing and scaling necessitated by a prevailing medical conditions and authorised by a doctor
  •   Tooth extractions including surgical extractions together with anesthetic fee

Exclusions under dental benefits

  •  Replacement or repairs of old dentures, bridges and plates unless directly caused by accidental injury.
  •  The cost of orthodontic treatment or any treatment of a cosmetic nature.

Optical Benefits

  • Expenses related to vision correction
  • Eye testing
  • The supply and fitting of eyeglasses and frames on a prescription only from the Company’s approved ophthalmologist
  • Eyeglasses are limited to one pair every two years,  unless otherwise proven to be medically necessary

Exclusions under optical benefits

  •   Replacement of optical frames in a period of less than 2 years from the date of issue
  •   Replacement of lenses unless prescribed by a qualified ophthalmologist as necessary
  •   Laser eye surgery
  •   Plano lenses and photochromatic lenses

Policy Terms And Conditions

1. Waiting Period

  • 21 days for outpatient illnesses
  • 45 days for inpatient admission
  • 90 days for surgical cases
  • One year (12 months) for maternity
  • One year for pre-existing, chronic and psychiatric condition
  • 12 months for congenital conditions
  • One year (12 months) waiting period for maternity, First emergency C/S and maternity related conditions.
  • None for accident
  • Two years (24 months) for cancer treatment
  • One year (12 months) for removal of fibroids, uterus, adenoids, tonsils, lipomas and repair of hernias
  • One year (12months) for optical laser treatment

2. Eligibility

  • Adults - 19 years and above
  • Children (38 weeks) full term and discharged from hospital to 18 years
  • Maximum joining age 60 years, existing members covered for life.
  • Eligible dependants include the spouse, own children and legally adopted children.
  • Medical reports for new applicants over 57 years will be required.

3. Requirements

  • Fully filled medical application form
  • Certified copies of the national ID and birth certificate for children
  • Full annual premium

4. Medical  Examination

  • Persons over 57 years will be required to submit a medical report from our selected service providers at their own cost

5. Settlement of Service Provider Bill

  • All inpatient bills will be paid net of NHIF rebate
  • All outpatient bills will be paid net of co-pay
  • There will be no refund for payment made directly by the insured to any service provider as Madison provides credit facilities through an approved panel of service provider
  • Madison insurance is liable for all bills up to the selected cover limits only
  • Any exceeded amount is payable by the insured member

6. Inpatient Management

Emergency Admission
       •   Each member is issued with a membership card for identification with the service provider
       •   Services are offered on presentation of the Madison Insurance Medical card and authentication of the member’s identity
       •   All members are required to produce their NHIF cards prior to discharge for purposes of NHIF rebate computation
       •   In the absence of the NHIF card, members will be required to pay the NHIF rebate in cash.

Scheduled Admissions
These refer to all non emergency admissions.

  •  The patient will agree with the doctor on the date of admission
  •  The doctor will then complete an inpatient pre-authorization form
  •  The form should be presented to Madison in advance, but at least 48 hours prior to admission
  •   Madison will evacuate the condition under the treatment and if covered, a letter of undertaking will be issued to the hospital with a copy to the patient
  •   On the admission date the patient will be required to present a letter of undertaking to the hospital.
  •   At discharge the patient is required to produce his/her NHIF card as above
  •   Ensure to sign a claim form and the final invoice

7. Outpatient Management

 Co-payment of Kshs. 500 shall be applicable for outpatient visits to:

  • The Aga Khan University Hospital
  • Nairobi Hospital
  • Karen Hospital
  • Gertrude’s Garden Children’s Hospital

  Co-payment of Kshs. 200 shall be applicable in outpatient’s visits to all other service providers

  • The outpatient cover excludes all dental and optical treatment and private vaccines
  • Members should sign all outpatients’ bills before leaving the hospital

How do I Sign for Cover?

  • Contact Madison insurance offices or your intermediary and complete an application form
  • The application form is available on our website: www.madison.co.ke
  • Members will be issued with a medical card and a policy document upon approval of the proposal

Exclusions

  1. Illness occurring within the waiting period
  2. Expenses incurred in connection with the venereal disease
  3. Expenses incurred in relation to and or in connection with the ritual circumcision
  4. Expenses incurred in relation to intentional self injury, attempted suicide, domestic violence, deliberate exposure to exceptional danger and hazardous sports.
  5. Medical expenses incurred as a result of infertility, Impotence or in the course of treatment to correct the cause of infertility,family planning and hormonal replacement therapy.
  6. Cosmetic treatment
  7. Medical expenses incurred outside Madison Insurance panel of service providers
  8. Expenses as a result of acts of terrorism and war
  9. Expenses incurred where material information is withheld or misstated
  10. Expenses incurred in connection with drunkenness, treatment of chronic alcoholism, intoxication, use of drugs not prescribed by a physician or drug addiction
  11. Nutritional food supplements and weight management
  12. Chiropractors, acupuncturists, and herbalists fee
  13. Medical checkups
  14. Private vaccines except KEPI recommended vaccine for children
  15. Benefits not specified in the brochure or policy document
  16. Outpatient ambulance services

NB: The policy document, application form and the policy schedule will be read as one document.

Rates

Per person (Individual Limits)

 Inpatient Benefits (Rates in Ksh)

 Overall Cover Limit
 300,000 500,000 1,000,000 2,000,000
 3 Months - 18 Years
  8,430 10,535 12,66016,882
            19 -29 Years
 12,884 15,688 18,971 23,329
 30 - 39 Years 15,545 18,134 21,70627,155
 40 - 49 Years
 18,275 21,501 26,24434,282
  50 - 59 Years 24,345 29,310 35,75846,708
  60 - 64 Years 28,472 31,654 42,45058,444
 65 - 70 Years
 30,025 32,047 46,65164,244

 

Outpatient Benefits (Rates in Ksh)

 Overall Cover Limit
 30,000 50,000 75,000 100,000
 3 Months - 29Years
 11,090 17,970 21,662 26,408
           30 - 39 Years 12,594 19,267 23,143 28,127
           40 - 49 Years
 13,810 21,150 25,413 30,895
           50 - 54 Years 16,484 25,291 30,408 36,986
  55 Years and above
 19,693 30,262 36,401 44,295

 

Maternity Rates (Rates in Ksh)

Limit
Premiums
50,000
 22,641
 75,000 30,175
100,000
  35,198

Alpha Family Health

Why Madison Alpha Family Health?

  • Access to countrywide service provider network
  • Smart card based
  • Declared pre-existing chronic, non chronic and AIDS
  • Lodger fees for children below 8 years of age
  • Overseas emergency treatment for the first 45 days of travel
  • Local emergency road and air evacuation
  • Psychiatric illness
  • First emergency cesarean section
  • Congenital conditions
  • Inpatient non accidental optical benefit including laser treatment
  • Inpatient non accidental dental benefit
  • Post hospitalization review expenses up to 21 days after discharge
  • Free last expense

Main Benefits

In-Patient Benefits

  • Admission in a NHIF accredited hospital
  • Accommodation for parent/ guardian accompanying a child below 8 years
  • Doctors; surgeons; and specialist’s fees
  • Laboratory investigations, X-rays, ultra sound, ECG, MRI scans
  • Prescribed drugs, dressings, surgical appliances, and nursing procedures
  • Theatre charges including Surgeons and anesthetists fees
  • Intensive care (ICU)/High Dependency unit (HDU)
  • Radiotherapy, chemotherapy, physiotherapy
  • Gynecological treatment
  • Day Care surgery
  • Prematurity covered within the congenital conditions limit

Out-Patient Benefits

  • Consultation with a general practitioner and specialist
  • Diagnostic examinations
  • Prescription medicines
  • Outpatient procedures e.g. dressing
  • Immunizations and vaccinations for children (KEPI recommended)
  • Minor trauma treatment
  • Gynecological treatment

Maternity Benefits

  • Delivery expenses
  • Maternity related complications
  • Pre and post natal care
  • Caesarean section

Dental Benefits

  • Cost of fillings
  • Root canal
  • X-rays
  • Polishing and scaling necessitated by a prevailing medical conditions and authorised by a doctor
  • Tooth extractions including surgical extractions together with anesthetic fee

Exclusions under dental benefits

  • Replacement or repairs of old dentures, bridges and plates unless directly caused by accidental injury.
  • The cost of orthodontic treatment or any treatment of a cosmetic nature.

Optical Benefits

  • Expenses related to vision correction
  • Eye testing
  • The supply and fitting of eyeglasses and frames on a prescription only from the Company’s approved ophthalmologist
  • Eyeglasses are limited to one pair every two years, unless otherwise proven to be medically necessary

Exclusions under optical benefits

  • Replacement of optical frames in a period of less than 2 years from the date of issue
  • Replacement of lenses unless prescribed by a qualified ophthalmologist as necessary
  • Laser eye surgery
  • Plano lenses and photochromatic lenses

Policy Terms And Conditions

1. Waiting Period

  • 21 days for outpatient illnesses
  • 45 days for inpatient admission
  • 90 days for surgical cases
  • One year (12 months) for maternity
  • One year for pre-existing, chronic and psychiatric condition
  • One year (12 months) for congenital conditions
  • One year (12 months) waiting period for maternity, First emergency C/S and maternity related conditions.
  • None for accident
  • Two years (24 months) for cancer treatment
  • One year (12 months) for removal of fibroids, uterus, adenoids, tonsils, lipomas and repair of hernias
  • One year (12 months) for optical laser treatment

2. Eligibility

  • Adults - 19 years and above
  • Children (38 weeks) full term and discharged from hospital to 18 years
  • Maximum joining age 60 years, existing members covered for life.
  • Eligible dependants include the spouse, own children and legally adopted children.
  • Medical reports for new applicants over 57 years will be required.

3. Requirements

  • Fully filled medical application form
  • Certified copies of the national ID and birth certificate for children
  • Full annual premium

4. Medical  Examination

  •  Persons over 57 years will be required to submit a medical report from our selected service providers at their own cost

5. Settlement of Service Provider Bill

  • All inpatient bills will be paid net of NHIF rebate
  • All outpatient bills will be paid net of co-pay
  • There will be no refund for payment made directly by the insured to any service provider as Madison provides credit facilities through an approved panel of service provider
  • Madison insurance is liable for all bills up to the selected cover limits only
  • Any exceeded amount is payable by the insured member

6. Inpatient Management

Emergency Admission

  • Each member is issued with a membership card for identification with the service provider
  • Services are offered on presentation of the Madison Insurance Medical card and authentication of the member’s identity
  • All members are required to produce their NHIF cards prior to discharge for purposes of NHIF rebate computation
  • In the absence of the NHIF card, members will be required to pay the NHIF rebate in cash.

Scheduled Admissions

  • These refer to all non emergency admissions.
  • The patient will agree with the doctor on the date of admission
  • The doctor will then complete an inpatient preauthorization form
  • The form should be presented to Madison in advance, but at least 48 hours prior to admission
  • Madison will evacuate the condition under the treatment and if covered, a letter of undertaking will be issued to the hospital with a copy to the patient
  • On the admission date the patient will be required to present a letter of undertaking to the hospital.
  • At discharge the patient is required to produce his/her NHIF card as above
  • Ensure to sign a claim form and the final invoice

7. Outpatient Management

  • Co-payment of Kshs. 500 shall be applicable for outpatient visits to:
  • The Aga Khan University Hospital
  • Nairobi Hospital
  • Karen Hospital
  • Gertrude’s Garden Children’s Hospital
  • Co-payment of Kshs. 200 shall be applicable in outpatient’s visits to all other service providers
  • The outpatient cover excludes all dental and optical treatment and private vaccines
  • Members should sign all outpatients’ bills before leaving the hospital

How do I Sign for Cover?

  • Contact Madison insurance offices or your intermediary and complete an application form
  • The application form is available on our website: www.madison.co.ke
  • Members will be issued with a medical card and a policy document upon approval of the proposal

Exclusions

  1. Illness occurring within the waiting period
  2. Expenses incurred in connection with the venereal disease
  3. Expenses incurred in relation to and or in connection with the ritual circumcision
  4. Expenses incurred in relation to intentional self injury, attempted suicide, domestic violence, deliberate exposure to exceptional danger and hazardous sports.
  5.  Medical expenses incurred as a result of infertility, Impotence or in the course of treatment to correct the cause of infertility,family planning and hormonal replacement therapy.
  6.  Cosmetic treatment
  7. Medical expenses incurred outside Madison 
  8. Insurance panel of service providers
  9. Expenses as a result of acts of terrorism and war
  10. Expenses incurred where material information is withheld or misstated
  11. Expenses incurred in connection with drunkenness, treatment of chronic alcoholism, intoxication, use of drugs not prescribed by a physician or drug addiction
  12. Nutritional food supplements and weight management
  13. Chiropractors, acupuncturists, and herbalists fee
  14. Medical checkups
  15. Private vaccines except KEPI recommended vaccine for children
  16. Benefits not specified in the brochure or policy document
  17. Outpatient ambulance services

NB: The policy document, application form and the policy schedule will be read as one document.

Rates

Shared Family Cover

Inpatient premium Table (Annual Rate per Family in Ksh)

Overall Cover Limit
300,000
 500,000 1,000,000 2,000,0003,000,000
 5,000,000
 Member+1  21,374  24,934
     29,846     37,388    43,313     68,750
Member+2  25,863  30,170     36,113     45,179    52,408     83,188
 Member+3  30,352  35,407     42,381     53,020    61,504     97,625
 Member+4  34,840  40,643     48,649     68,861    70,599    112,603
 Member+5  39,329  45,879     54,916     68,702    79,695    126,500
Member+6  43,817  51,115     61,184     76,543    88,791    140,938
 Member+7  48,306  56,351     67,451     84,384    97,886    155,375
 Member+8  52,795  61,588     73,719
     92,225
  106,982
    169,813
Extra   4,489   5,236       6,268       7,841     9,096      14,438

 

Outpatient premium table (Annual Rate per Family)

Overall Cover Limit 50,00075,000
100,000
 150,000
Per Member 21,15025,413
  30,895
 37,352
 Member+1 29,08134,943  42,481 51,359
 Member+2 35,18842,281  51,402 62,144
 Member+3 41,29549,619  60,322 72,930
 Member+4 47,40256,957  69,243 83,715
 Member+5 N/A64,295  78,164 94,501
Extra
 N/A  7,338    8,921 10,785

 

 Maternity Rates (Rates in Ksh)

Limit
Premiums
50,000
 22,641
 75,000 30,175
100,000
  35,198

Alpha Budget Plan

Why The Budget Plan?

  • Access to quality and affordable, countrywide service provider network
  • Declared pre Existing chronic, non-chronic and HIV/AIDS
  • Newly diagnosed chronic conditions
  • Lodger free for children below 8 years of Age
  • Overseas treatment on referral
  • Psychiatric illness cover
  • Maternity cover
  • First emergency caesarean section cover
  • Congenital Conditions Cover
  • Inpatient Non accidental optical cover
  • Inpatient Non Accidental Dental Cover
  • Free Last Expense

Main Benefits

      In – patient Benefits

  • Admission in a NHIF accredited hospital
  • Accommodation for parent/guardian accompanying a child below 8 years
  • Doctor’s, surgeons, and specialist fees
  • Laboratory investigations, X-Rays, Ultrasound, CT scan( with prior authorization)
  • Prescribed drugs, dressing, surgical appliances, and nursing procedures
  • Theater including surgeon’s fees and anesthetists fees
  • Intensive care (ICU) High dependency unit (HDU)
  • Radiotherapy, chemotherapy, physiotherapy
  • Gynecological treatment
  • Day care surgery

   Outpatient Benefits

  • Routine outpatient consultation as per negotiated rates  
  • Prescription medicines
  • Prescription routine laboratory tests
  • Immunizations and vaccinations for children (KEPI recommended)
  • Outpatient procedures e.g. dressing
  • Routine dental services such as extractions, filling, polishing and scaling


   Maternity Benefits

 

  • Delivery expenses (normal and elective caesarean section)
  • Maternity related complications

 

Policy Terms And Conditions

 

1. Waiting period for inpatient and outpatient

  • 0 days for accidents
  • 21 days for outpatients illnesses
  • 45 days for inpatient admissions
  • 90 days for surgical cases
  • One year (12 months) for maternity, emergency caesarean sections and maternity related complications
  • One year (12 months) fir pre Existing chronic, congenital and psychiatric conditions
  • Two years (24 months) for cancer treatment
  • One year (12 months) for myomectomies hysterectomies, adenotonsilectomy lipomas and hernias
  • N.B Chronic conditions diagnosed within 6 months of joining will be considered pre-existing and covered under the pre-existing and chronic conditions limit.

2. Eligibility

  • Adults – 19 and above
  • Children – 38 weeks (medically discharged) to 18 years extended up to 25 years with evidence of schooling
  • Maximum joining age 60 years
  • Eligible dependent include the spouse, own children and legally adopted children
  • Medical reports for new customers over 57 years will be required
  • Cover renewable for life subject to underwriting review


3. Requirements at Inception

  • Fully filed medical application form
  • Certified copies of the national ID and birth certificate for children
  • Full annual premium
  • Passport size photos


4. Medical  Examination

  • Persons over 57 years will be required to submit a medical report from our selected service provider at their own cost
  • Settlements of service provider bills
  • Members are treated and  discharged under their cover limits
  • All inpatient bills will be paid net of NHIF rebate
  • All outpatient bills will be paid net of co pay where applicable
  • There will be no refund for payment made directly by the insured to any  service provider as Madison provides credit facilities through an approved panel of service providers.

5. Settlement of Service Provider Bill

  • All inpatient bills will be paid net of NHIF rebate
  • All outpatient bills will be paid net of co-pay
  • There will be no refund for payment made directly by the insured to any service provider as Madison provides credit facilities through an approved panel of service provider
  • Madison insurance is liable for all bills up to the selected cover limits only
  • Any exceeded amount is payable by the insured member

6. Inpatient Management

Emergency Admission:

  • Each member is issued with a membership card for identification with service providers
  • Services are offered on presentation of the Madison Insurance medical card and authentication of the member’s identity
  • Notify Madison insurance  of an emergency admission with 24hours of admission
  • All members are required to produce their NHIF cards prior to discharge for purposes of NHIF rebate computation in the absence of the NHIF card members will be required to pay NHIF rebate in cash


Scheduled Admissions

  • These refers to all non  emergency admissions
  • The patient will agree with the doctor on the date of admission
  • The doctor will then complete an inpatient pre-authorization form
  • The form is sent or brought to Madison in advance, but at least 48 hours prior to admission
  • Madison will evaluate the condition under treatment and if covered, a letter of undertaking will be issued to the hospital with a copy to the patient
  • On the admission date, the patient will be required to present the letter of undertaking to the hospital
  • At discharge, the patient is required to produce his/her NHIF card as above
  • All inpatient bills are sent directly to Madison for processing and payment

7. Outpatient Management

 

  • Co payment of Kshs.200 shall be applicable for all outpatient visits
  • The outpatient cover excludes all optical benefit and private vaccines
  • Dental services will be accessed at the listed hospitals

 


How do I Sign for Cover?

 

  • Contact Madison insurance offices or your intermediary and complete an application form
  • The application form is also available on our website www.madison.co.ke
  • Members will be issued with a medical card and a policy document upon approval of the proposal

Exclusions

  1. Accident or illness occurring before or after the date of the cover or illness occurring within the waiting period
  2. External prosthesis (wheelchair, walking stick e.t.c) unless necessitated by an accident
  3. Expenses incurred in connection with venereal disease
  4. Expense incurred in relation to and or in connection with ritual circumcision
  5. Expense incurred in relation to intentional self-injury, attempted suicide, deliberate exposure to exceptional danger and hazardous sports 
  6. Medical expenses incurred as a result of infertility, impotence or in the course of treatment to correct the cause of infertility, family planning and hormonal replacement therapy 
  7. Cosmetic treatment
  8. Physiotherapy ( unless necessitated by an accident)
  9. Diagnostic equipment ( e.g. glucometer, BP machines e.t.c) and hearing aids
  10. Unproven and experimental treatment
  11. Expenses as a result of acts of terrorism and war
  12. Expenses incurred where material information is withheld or misstated
  13. Expenses incurred in connection with drunkenness, treatment of chronic alcoholism, intoxication, use of drugs not prescribed by a physician or drug addiction
  14. Nutritional food supplements, weight management and medical expenses incurred to any visit to chiropractors, acupuncturists, and herbalist
  15. Medical expenses incurred outside Madison insurance panel of service providers
  16. Optical treatment
  17. Medical checkups
  18. Private vaccines except kepi recommended vaccines for children
  19. Outpatient ambulance services
  20. MRI
  21. Benefits not specified in the brochure or policy document
  22. NB: THE POLICY DOCUMENT, APPLICATION FORM AND THE POLICY SCHEDULE WILL BE READ AS ONE DOCUMENT

Rates

Budget Plan Rates

Inpatient 

Premium Per Shared Limit Per Family per Annum

Overall Cover Limit
250,000
 350,000 500,000 750,0001,000,000 
 1,500,000
 Member 10,750 14,000    15,500     17,06318,000 21,646
Member+1  14,781  19,250     21,313    23,46224,75029,763
 Member+2  17,885  23,293     25,788     28,389    29,94836,014
 Member+3 20,989  27,33530,264     33,316    35,145 42,264
 Member+4 24,093 31,378     34,739     38,24240,34348,514
Member+5  27,198  35,420     39,215     43,16945,54054,764
 Member+6 30,302  39,463     43,691     48,09650,738    61,015
 Member+7  33,406  43,505     48,166 
     53,023 
55,93567,265
Member+8   36,510   47,548       52,642       57,95061,13373,515 

Outpatient

Premium Per Shared Limit Per Family per Annum

Overall Cover Limit
30,000
 50,000 65,000 80,000100,000 
 
 Member 9,02015,45717,241 19,619 21,997 
Member+112,40321,253     23,706    26,97630246 
 Member+2  17,885  23,293     25,788     28,389    29,948 
 Member+319,884 30,180 33,66338,306    42,949 
 Member+4 23,33534,64338,64143,97149,301 
Member+526,786  39,10643,620  49,636 55,652 
 Member+629,84343,56948,59855,30162,004    
 Member+7   48,033     53,57660,96668,356 
Member+8           58,555        66,631 74,707 

 

 

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